Occupational Health and

Safety Technologist

APPLICATION FORM
Board of Certifed Safety
Professionals
2301 W. Bradley Avenue
Champaign, Illinois 61821
P: +1 217-359-9263 | F: +1 217-359-0055
E: bcsp@bcsp.org | W: www.bcsp.org
Type or print legibly. See the OHST Candidate Handbook for instructions on completing this form. View and print additional copies at www.bcsp.org/OHST.
SUMMARY OF HEALTH AND SAFETY EXPERIENCE
(You must complete an OHST Experience Form for each position listed on your application in order to receive credit.)
POSITION
(List your most recent position frst)
EMPLOYER START
DATE
(MM/YY)
END
DATE
(MM/YY)
MONTHS
IN POSITION
EDUCATION (If you are seeking degree or college credit toward certifcation, you must enclose an offcial transcript.)
I am a high school graduate or have a GED certifcate.
COLLEGE OR UNIVERSITY OR
CERTIFICATE PROVIDER
(Name, City, State)
DATES ATTENDED NUMBER OF
ACADEMIC YEARS
COMPLETED
(For Degrees)
COURSE OF STUDY OR
MAJOR OR CERTIFICATE
TITLE
DEGREE
EARNED
TRANSCRIPT OR
CERTIFICATE
(Check One)
FROM
(MM/YY)
TO
(MM/YY)
Enclosed
School Sending
Certifcate Copy Enclosed
Enclosed
School Sending
Certifcate Copy Enclosed
For Offce Use Only
Date Eligible for OHST Examination: __________
For Offce Use Only
Date Eligible for OHST Certifcation: __________
NAME
Mr. Ms.
First MI Last/Family Maiden Name (if applicable) Other Legal Name (if applicable)

HOME SOCIAL SECURITY NUMBER
ADDRESS
Street Address Apartment Box Number
DATE OF BIRTH (MM/DD/YY)

City State/Province
NAICS CODE (See Table 2)

Zip/Postal Code Country 1. 2.
PHONE NUMBERS HOME PHONE (Area Code & Number) WORK PHONE (Area Code & Number) FAX (Area Code & Number)
(If outside the U.S. or Canada,
include country and city codes)
MOBILE (Area Code & Number) EMAIL ADDRESS(ES)
APPLICANT PERSONAL DATA
CSP PE COHN-S STS
CIH CHCM CPE Marine Chemist
CHP CHMM RN CET
CHST COHN RPT Other _____________________________________________________________________________________________

Occupational Safety Industrial Hygiene Radiation Safety
General Safety Transportation Safety Product Safety
Fire Protection System Safety Construction Safety
Environmental Process Safety Training Other _________________________________________________________
1. Have you ever been convicted of a felony? YES NO
2. Have you been convicted of a misdemeanor within the last 5 years? YES NO
3. Do you have a record of any unethical behavior? YES NO
4. Have you ever had a professional registration, license or certifcation denied, suspended or revoked other than for lack of minimum qualifcations, failure of
examination, or failure to pay renewal fees?
YES NO
(If you answered YES to any of the questions 1-4, you must complete the Criminal Conviction & Professional Registration, Certifcation, or License Information Form avail-
able at www.bcsp.org/pdf/ccform.pdf).
5. I understand that any falsifcation of information on this application including any attachments or supplemental materials, provided now or later, may be cause
for rejection or withdrawal of certifcation or such other action as BCSP may deem appropriate. I certify that the statements above (including any attachments
submitted, now or later) are accurate to the best of my knowledge. I hereby authorize BCSP to verify any information or supplements submitted.
6. I agree to hold BCSP harmless from any and all liability in the event this application is rejected on the basis of information furnished to BCSP by me or other
persons which would, in the judgment of BCSP, make me ineligible for certifcation.
7. With this application, I hereby authorize BCSP to publish in all of its directories or registries my name, city, state, country, and any certifcation it issues to me.
BCSP will make every effort to keep your personal and examination information confdential. BCSP will obtain your approval prior to releasing information
from your BCSP records, other than directories, verifcation of your certifcation to the public or a court subpoena for your records.
8. I agree to adhere to the BCSP Code of Ethics in its current and subsequent editions and, if I am certifed, to meet the requirements for Recertifcation (see
http://www.bcsp.org/pdf/BCSPcodeofethics.pdf).
______________ _________________________________________
Date Signature
VALIDATION AND SIGNATURE
(Be sure to sign and date your application or it cannot be processed. Your signature means you agree with the following statements.)
OHST APPLICATION PAYMENT INFORMATION
(The application fee is nonrefundable and subject to change.)
03/2014
SAFETY SPECIALTIES
PROFESSIONAL SOCIETY MEMBERSHIPS
(Check all that apply.)
ACGIH ASSE HPS SFPE IIE NFPA
AIHA HFES NSMS SSS NSC NESHTA Other ______________________________________________
CURRENT LICENSES, REGISTRATIONS AND CERTIFICATIONS
(Check all that apply.)
M M Y Y
Credit/Debit Card Number
FEE PAID BY CREDIT/DEBIT CARD AUTHORIZATION

Check or Money Order
(U.S. dollars only)
Make checks payable to:
BCSP
Name as it Appears on Card
American Express
Discover/Novus
MasterCard
VISA
Expiration Date
Billing Address Signature
$140
CVV/CVV2